Ebola cases declined last week in all three of West Africa's hardest-hit countries last week, but new cases continue to be detected, especially in western Sierra Leone, the World Health Organization (WHO) said today in its weekly situation report.

Sierra Leone—the worst-affected country—reported 184 new confirmed cases last week, compared with 42 in Guinea and 8 in Liberia, according to the WHO. The new cases lift the epidemic total to 21,296 illnesses, with 8,429 deaths.

Two-week dip in Sierra Leone

In Sierra Leone, case incidence declined for the second week a row. About two-thirds of the new cases were reported in Freetown and neighboring Port Loko and Western Rural districts. Other hot spots included Kambia, which borders Port Loko and an area of Guinea where the disease is flaring. In eastern Sierra Leone, 14 cases were reported in Kono district, which borders Guinea.

Guinea's cases also declined for the second week a row, tumbling to their lowest level since the middle of August, with illnesses in Conakry—one of the country's ongoing hot spots—at the lowest level since November.

The WHO said Guinea's worst-affected district last week was Forecariah, with 12 cases, with Conakry reporting 9 illnesses. No new cases were reported from Fria district, which had confirmed its first Ebola infections the previous week.

Of Liberia's eight new cases, four were reported in Montserrado County, which includes the capital, Monrovia, and Grand Cape Mount district, the WHO said. It also pointed out how dramatically Liberia's cases have dropped over the past few months, from a peak incidence of 300 new cases per week in August and September to just eight last week.

Among healthcare workers, five more illnesses and five more deaths were reported last week in the three countries, lifting the total to 825, which includes 493 deaths.

Response assessments

In its assessment of response activities, the WHO said all three countries have the capacity to isolate and treat patients, but the uneven distribution of treatment beds in some areas means not all Ebola patients are isolated, a key step in curbing transmission. Several districts, especially in Guinea, are still located far from Ebola treatment centers.

The WHO added that each of the countries has the capacity to bury all those who die from Ebola, but underreporting of deaths means not all burials are handled safely.

Community engagement is a key driver of response activities such as contact tracing and safe burials, but the countries vary in their ability to monitor engagement, with Liberia at 100% of districts, Guinea at 87%, and Sierra Leone at 57%.

Looking specifically at contact tracing, the percentage of registered contacts visited daily ranged from 84% in Sierra Leone to 99% in Liberia, according to the WHO. However, it said the percentage was lower in several districts.

All 54 districts in the outbreak countries that have had probable or confirmed Ebola cases have access to a lab within 24 hours of sample collection. So far, 27 labs in the region can confirm Ebola cases, with five more to be deployed: three in Guinea, one in Liberia, and one in Sierra Leone.

MSF activity update

Doctors without Borders (MSF), which has been working on West Africa's Ebola response since the outbreak emerged in March, issued an overview of the outbreak and its response activities yesterday. It said that though the number of new cases in Guinea has been relatively stable over the last 3 weeks, the situation is still concerning, because the virus is continuing its geographic spread, with new districts declaring their first cases.

In Sierra Leone, the outcome of a western response surge launched on Dec 16, targeting the door-to-door identification of Ebola cases, is still unknown. MSF said increases in Ebola hotline calls and case detections at its treatment center in Freetown were substantially less than expected, which might signal a shortfall in the social mobilization effort. It added that hotline calls increased 10% and positive cases at the Freetown center increased slightly.

Meanwhile in Liberia, MSF said there are up to three active transmission chains in Grand Cape Mount County, including one in an open-cut mine. Based on a recent evaluation, an MSF team has decided to run mobile clinics in villages across the region to identify active cases, teach local health staff about triage and infection control, and fill gaps in primary healthcare.

MSF said some areas across the region still lack adequate facilities for isolating and diagnosing patients. As of Dec 30, nearly 3,800 MSF staff were deployed to West Africa, and the virus has sickened 27 of them, 13 fatally.

The group added that some parts of West Africa have gaps in elements that are crucial for the Ebola response, such as community sensitization, safe burials, contact tracing, surveillance, and access to healthcare for other medical conditions.

Other developments

Today's update from the United Nations Mission for Ebola Emergency Response (UNMEER) touches on issues and challenges related to the region's recovery from the outbreak. It said the UN Development Program is conducting early recovery assessments in the three outbreak countries. The team already visited Liberia, is in Sierra Leone today, and will travel to Guinea before compiling an early recovery plan for the countries. A border market has reportedly reopened in Foya, Liberia, a site that brings people together from all three outbreak countries for an exchange of foods and services. UNMEER said volunteers in the area have reported concerns since Ebola cases are still being reported in neighboring districts, and an assessment team will visit Foya to assess the situation and make recommendations.

Experts writing in two recent British Journal of Obstetrics and Gynaecology (BJOG) commentaries said obstetric interventions in Ebola settings are deeply challenging. In the first report, Benjamin Black, MBBS, MSc, who works with MSF in Sierra Leone, said one challenge is that clinicians must differentiate between a woman presenting with an obstetric emergency that requires rapid intervention and one who may have Ebola, which requires limiting invasive procedures. He said obstetrics cases expose health workers to body fluids such as blood, amniotic fluid, urine, and feces, posing a very high risk of transmission for Ebola. Black added that meeting maternal health needs while the outbreak is underway will require an ongoing assessment to minimize risks to health workers while allowing them to provide lifesaving care. In the second commentary, three experts from Public Health England (PHE) discussed Ebola in pregnancy and the evidence for transmission and clinical outcomes. They concluded that there are very few studies on maternal and fetal outcomes, and though high neonatal mortality rates have been reported, it's not always known if the deaths were caused by Ebola or other causes.

Health and law enforcement officials in Fort Hood, Tex., are investigating the death of a soldier who recently returned on emergency leave from serving in West Africa, but preliminary and polymerase chain reaction (PCR) tests are negative for Ebola. In a press release, the base said the solider, named as Sgt Kendrick Vernell Sneed, was under guidelines for twice-a-day self-monitoring, but there is no indication of Ebola disease or a health threat. He was found dead yesterday at his off-post residence in Killeen, Tex.